A transitional care unit (TCU) is a short-stay rehabilitation setting for an older adult who is well enough to leave the hospital but not yet ready for the stairs, the bathroom and the kitchen at home. Home-based rehabilitation does the same work the other way round: a therapist comes to you, on scheduled visits, in your own living space. We provide the therapy in both. Our Inpatient Services cover residential, transitional and short-stay settings, and our Home-Based Services cover therapy at home. Below is what each one involves, where our transitional care unit therapy is available, and what to raise with the healthcare team before a discharge date is set.
What Is a Transitional Care Unit?
A transitional care unit is a short-stay setting where you keep practicing the movements that daily life asks for, with therapy built into the day, before you go home. Hospitals plan for this step. A discharge planner helps decide whether you go home or to another setting, and MedlinePlus describes that choice as part of the discharge plan, along with the help you may still need once you are back.
Our part in it is the therapy. We are the therapy provider, not the operator of the unit. Services are available at select senior living communities for residents and older adults who live elsewhere. We also provide home-based programs.
What Happens During Transitional Care Therapy
Therapy is shaped around what you are trying to get back to. Depending on what the setting provides, it may include:
- Physical Therapy: posture, balance, strength, pain management, mobility in and out of furniture, walking, stairs
- Occupational Therapy: bathing, dressing, cooking, cleaning, money management
- Speech Therapy: speaking, understanding and swallowing, for communication and social dining
MedlinePlus lists the same three therapies as part of a rehabilitation plan, and notes that rehabilitation may take place in an inpatient setting or, in some cases, with a provider coming to your home.
Our Inpatient Services are traditional inpatient physical therapy, occupational therapy and speech therapy with programming specialized for the senior population, delivered in residential, transitional and short-stay settings. Our short-stay rehab clients receive the intensity of therapy needed during an appropriate length of stay for their condition.
In transitional care settings, we provide specialty care for patients recovering from knee, hip or shoulder surgery, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and other conditions.
Where Our Transitional Care Unit Therapy Is Available
This is the part a family needs in writing, so here it is plainly: our transitional care unit therapy runs at two of our locations, not across all twelve.
At Oxbow and Woodbury we provide PT/OT/ST on TCU, Skilled nursing, and outpatient for apartment residents, community members. We also provide Fitness services to residents and community members.
Those two are Saint Therese at Oxbow Lake in Brooklyn Park and Saint Therese of Woodbury in Woodbury. Ascend Rehab TCU services are available seven days a week.
Our other ten locations are listed with Outpatient/Home Care Therapies, several of them with Fitness Services as well. If you are hoping for transitional care therapy somewhere else on the list, call us before you plan around it rather than assuming it runs there. You can see the full set on our 12 locations across the Twin Cities.
How Is a Transitional Care Unit Different From Therapy at Home?
Two differences matter: where the therapy happens, and who is around for the rest of the day.
In a transitional care unit you stay in the setting and practice everyday activities there. With home-based rehabilitation you stay at home and a therapist comes to you on scheduled visits, so the practice happens on your own stairs, in your own bathroom, with your own furniture.
Our part is the same in both: the therapy. The rest of the day belongs to the setting’s own team, or to the people already supporting you at home. In transitional care settings we also coordinate with interdisciplinary teams, nursing staff, physicians and social workers, without employing those roles as part of our therapy offering. We do not own or run the communities our services are available in. Ask the setting, or the home care agency, who is present between therapy visits, and settle that before a discharge date is fixed.
What to Weigh Before You Choose
Take these to the healthcare team rather than deciding them at the kitchen table:
- how much help is needed with getting up, moving between rooms and daily activities
- whether the home can be made workable, and what would have to change first
- whether scheduled visits are enough, or whether the day needs more structure than that
- what has to be arranged before discharge: equipment, transport, someone at home
- how progress will be reviewed, and how the family gets updates
Is the Home Workable?
A familiar home is reassuring, and it is also where the obstacles are. The National Institute on Aging’s room-by-room guidance on preventing falls at home asks for handrails on both sides of any stairs, grab bars inside and outside the tub and shower, and walking routes kept clear of books, papers, clothes and shoes.
A Safe-At-Home Assessment is how we look at that. A therapist observes getting in and out of bed, using a chair, managing stairs and preparing meals in your own home. A Safe-At-Home Assessment is considered a therapy visit and the cost is typically covered by insurance when ordered by a physician.
Moving From a Transitional Care Unit to Therapy at Home
A large portion of clients who require home-based services have completed a stay at a short-term, inpatient transitional care unit or at a long-term care facility. If that is the next step, our Home-Based Services are specialized home-based services for older adults, delivered in the comfort of your home through our partnerships with home care agencies. We are the therapy provider working with those agencies; we are not the agency. The goal is to age-in-place.
Before the move, ask the healthcare team about discharge recommendations, continuing therapy needs, and the practical arrangements for getting back into the house.
How We Support Older Adults After a Hospital Stay
Recovery moves in stages, and the support that fits changes with it. We provide therapy and wellness services for older adults throughout the Twin Cities, across four service lines:
- Inpatient Services: physical, occupational and speech therapy in residential, transitional and short-stay settings
- Outpatient Services: clinic-based physical, occupational, speech, aquatic and massage therapy for older adults
- Home-Based Services: specialized home-based services, through our partnerships with home care agencies
- Wellness & Fitness Services: group and individual fitness and wellness programming for residents and community members
Our goal is to keep older adults safe, active and independent.
Frequently Asked Questions
What should we arrange before a parent comes home from a transitional care unit?
Talk through the discharge recommendations, how much help is needed with moving around, what the home needs, any equipment, and who is available for daily activities. Working that out before the discharge date makes the first week at home steadier.
What should you ask before choosing a transitional care unit?
Ask which therapies are provided, how often they run, how progress is reviewed, how the family gets updates, and what has to be in place before discharge. Those answers tell you whether the setting matches what your parent is working toward.
How can a caregiver help after a transitional care stay?
Follow the healthcare team’s recommendations, get the living space ready, and keep to the daily routines that were agreed. It also helps to be clear on which activities need a second pair of hands and when to call the healthcare team.
What if someone still needs help after they get home?
Raise it with the healthcare team. Home-based therapy may be an option when continued rehabilitation is appropriate, and a Safe-At-Home Assessment can look at how the house is working day to day.
Services are available throughout the Twin Cities, call us to learn more. Schedule an appointment or call 763.531.5039.